How did hospitals begin to change from monastic to “secular”?

Reading Guenter Risse’s account, in Mending Bodies, Saving Souls, of how hospitals were pioneered and operated for many centuries by monks, I began to wonder–how and why did this situation change? How did we get from monastic hospitals to the huge, shiny, bureaucratic and largely secular institutions that loom on today’s medical landscape? Here is the beginning (but only the beginning) of the answer to my question:

“[In the 11^th century,] Benedictine monasteries throughout Europe ceased to play their hitherto prominent roles in the provision of social welfare and medical care. For almost 1,000 years, almshouses and hospitals had been organized and run in accordance with highly successful monastic models of prayer and work. Now, in the face of rapid population growth and urbanization, these establishments became inadequate purveyors of traditional charitable assistance. An increasingly urban economy based on commerce that demanded markets, contracts, and currency loans rapidly became the instrument and measure of work. Just at the time their own incomes started to decline, the monasteries’ almonries were overwhelmed by the growing influx of needy individuals, a reflection of new and more complex social and economic conditions affecting the European population.” (107)

This narrative of the secularization (or at least, since no aspect of medieval Western culture was truly secular, the laicization) of health care reminds me of an American parallel. Robert Wiebe, in The Search for Order: 1877-1920, details a similar shift, from older religious (usually Protestant evangelical) social institutions, including charitable organizations, of mid- to late 19^th-century America to the new secular bureaucracies of the Progressive era (1890s – 1920s).

Wiebe cited a similar growth in population, market systems, and complexity of social needs and institutions. Those who continued to defend older forms of social ministry anchored in Christian community—in which social services were handled by the church and parachurch—he called “transcendental escapers.” These people, he insisted, couldn’t handle the newly complex realities of modernization. These were antiquarian ostriches, sticking their collective heads into the sand of old, unworkable religious or quasi-religious ideals. The future lay with the progressive reformers, who turned increasingly away from the church and toward secular bureaucratic institutions.

But the actual secularization of hospitals, as we think of secularization, lies many pages further on in Risse’s account, in his treatment of Enlightenment-era developments. In the Middle Ages, we must still use the term “secular” as they did: to mean those areas of life deeply wedded to the saeculum—the concerns of this age, this temporal existence, as contrasted with the concerns of eternity, which animated monastic existence. In this sense of the term, priests, bishops, and even popes were classed as “seculars”—meaning not that they were somehow un-religious in the modern sense, but that they spent their days dealing with the affairs and problems of those living and ministering “in the world,” rather than in the eternally directed disciplines and contemplations of the cloistered life. In that sense, the increased involvement of non-monastic Christians, hospitals did begin to “secularize” rather early:

“By the late eleventh and twelfth centuries, Matthew’s six merciful acts[1] including visitation and care of the sick, had transcended the strict frontiers of ecclesiastical and monastic activities to become important guidelines for lay behavior. Together with a seventh, burying the dead, their inclusion in catechisms and devotional guides characterized them all, albeit stereotypically, as the accepted boundaries of Christ’s charitable work. Given the simultaneous and rather dramatic rise in poverty in the eleventh century, lay persons were now invited to join the clergy in performing these functions. Up to this time, the Church had successfully dealt with traditional poverty—usually at a personal level—but the presence of thousands of refugees crowding the new cities demanded greater participation by other sectors of the population. Working together with Episcopal and monastic authorities, urban parishes and confraternities[2] slowly began the institutionalization of social welfare in the cities. This task was based on the traditional Christian premise that such assistance was still part of a religious ritual and an important means for acquiring spiritual salvation. In fact, visiting the sick could bring plenary indulgences furnished by the pope. After 1300, such lay participation increasingly dislodged the original charitable Christian guesthouse or hospitium from its hitherto exclusive connections with monasteries and cathedral chapters. The stage was set for other actors to participate in the development of the hospital system.” (109)

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[1] From Matt 25:31 – 46: feeding the hungry, giving drink to the thirsty, clothing the naked, visiting and ransoming the captive (prisoners), sheltering the homeless, and “visiting” the sick—these would soon, with addition of “burying the dead,” from the Book of Tobit, become the ubiquitous medieval “seven corporal acts of mercy”

[2] These were lay organizations, episcopally approved, gathered for charitable ends.